Confidential Dhhs Restrictive Intervention Details Report - North Carolina Page 3
ADVERTISEMENT
1
2
3
4North Carolina Department of Health & Human Services – Division of Mental Health/Developmental Disabilities/Substance Abuse Services
DHHS Restrictive Intervention Details Report
CONFIDENTIAL
CONFIDENTIAL
-
-
Provider Agency Name
Consumer’s Name
Consumer’s Social Security No.
Page 3 Instructions: The supervisor of the service should review pages 1-2 of this form, complete page 3 and submit to the LME responsible for the
geographic area in which the service is provided. If a consumer dies or is permanently impaired as a result of the intervention, this report
must also be submitted to the consumer’s home LME and to DHHS (see addresses below). Consumer deaths within 7 days of a restrictive
intervention must be reported immediately. Providers have 72 hours to complete all other reports of restrictive intervention.
Name(s) of Staff Conducting Intervention
Current Certification
CPR
First Aid
NCI
CPI
Other
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Describe the debriefing with the individual and/or guardian:
Describe the debriefing with staff: (What could have been done differently to avoid the need for restrictive intervention in this situation? What can be done
to reduce the need for future restrictive interventions?)
Has the Person-centered Planning or Child & Family Team previously addressed this issue?
Yes
No
Does consumer have a crisis plan?
Yes
No
Was the current plan effective in addressing this issue?
Yes
No
Does consumer have a behavior plan?
Yes
No
Was the current plan used prior to the intervention?
Yes
No
Has the need for a crisis or behavior plan (or plan revision) been communicated to the service planning team?
Yes
No
Describe plans for follow-up:
Persons notified:
Name
Date
Time
Person-centered Planning Team Representative
am
pm
Host LME (specify)
am
pm
Legal Guardian
am
pm
Other (specify)
am
pm
Name/Title of Staff Completing Form
Signature:
Date
Name/Title of Supervisor
Signature:
Date
Name/Title of Program Director
Signature:
Date
Confidentiality of consumer information is protected under Federal regulations, 42 CFR Part 2 and HIPAA, 45 CFR Parts 160 & 164.
DMH/DD/SAS-Community Policy Management Section – Form QM04
Effective October, 2004 – Rev. 11/18/04
Page 3 of 4
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal